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Observational Study
. 2019 Jan 24;16(1):e1002737.
doi: 10.1371/journal.pmed.1002737. eCollection 2019 Jan.

Evaluating Strategies for Control of Tuberculosis in Prisons and Prevention of Spillover Into Communities: An Observational and Modeling Study From Brazil

Free PMC article
Observational Study

Evaluating Strategies for Control of Tuberculosis in Prisons and Prevention of Spillover Into Communities: An Observational and Modeling Study From Brazil

Tarub S Mabud et al. PLoS Med. .
Free PMC article

Erratum in


Background: It has been hypothesized that prisons serve as amplifiers of general tuberculosis (TB) epidemics, but there is a paucity of data on this phenomenon and the potential population-level effects of prison-focused interventions. This study (1) quantifies the TB risk for prisoners as they traverse incarceration and release, (2) mathematically models the impact of prison-based interventions on TB burden in the general population, and (3) generalizes this model to a wide range of epidemiological contexts.

Methods and findings: We obtained individual-level incarceration data for all inmates (n = 42,925) and all reported TB cases (n = 5,643) in the Brazilian state of Mato Grosso do Sul from 2007 through 2013. We matched individuals between prisoner and TB databases and estimated the incidence of TB from the time of incarceration and the time of prison release using Cox proportional hazards models. We identified 130 new TB cases diagnosed during incarceration and 170 among individuals released from prison. During imprisonment, TB rates increased from 111 cases per 100,000 person-years at entry to a maximum of 1,303 per 100,000 person-years at 5.2 years. At release, TB incidence was 229 per 100,000 person-years, which declined to 42 per 100,000 person-years (the average TB incidence in Brazil) after 7 years. We used these data to populate a compartmental model of TB transmission and incarceration to evaluate the effects of various prison-based interventions on the incidence of TB among prisoners and the general population. Annual mass TB screening within Brazilian prisons would reduce TB incidence in prisons by 47.4% (95% Bayesian credible interval [BCI], 44.4%-52.5%) and in the general population by 19.4% (95% BCI 17.9%-24.2%). A generalized model demonstrates that prison-based interventions would have maximum effectiveness in reducing community incidence in populations with a high concentration of TB in prisons and greater degrees of mixing between ex-prisoners and community members. Study limitations include our focus on a single Brazilian state and our retrospective use of administrative databases.

Conclusions: Our findings suggest that the prison environment, more so than the prison population itself, drives TB incidence, and targeted interventions within prisons could have a substantial effect on the broader TB epidemic.

Conflict of interest statement

I have read the journal’s policy and the authors of this manuscript have the following competing interests: SB receives a stipend as a specialty consulting editor for PLOS Medicine and serves on the journal’s editorial board.


Fig 1
Fig 1. Flow diagram of database linkage and selection of individuals for survival analyses.
MS, Mato Grosso do Sul; SIGO, Sistema Integrado de Gestão Operacional; SINAN, Sistema de Informação de Agravos de Notificação; TB, tuberculosis.
Fig 2
Fig 2. Incidence of TB among (A) Mato Grosso do Sul prisoners and (B) ex-prisoners based on length of incarceration and length of time following incarceration, respectively, with 95% bootstrap confidence intervals in blue shading.
Histograms of individuals included in each survival analysis are overlaid. TB, tuberculosis.
Fig 3
Fig 3. Compartmental model of TB transmission, describing the progression of disease from susceptible (S) to early latent infection (E), late latent infection (L), infectious (I), and recovery (R) among prisoners (subscript p, pink boxes), ex-prisoners (subscript e, purple boxes), and other community members (subscript c, blue boxes).
Solid arrows represent the dynamics of TB transmission, whereas dotted arrows represent the dynamics of incarceration and release from prison. The prison environment is shaded blue to distinguish it from the external environment, which comprises ex-prisoners and other community members. TB, tuberculosis.
Fig 4
Fig 4. Proportionate decrease in TB incidence over 10 years according to various prison-based interventions.
Box and whisker plots describe uncertainty in intervention effectiveness produced by Latin Hypercube Sampling analysis; boxes characterize 25th, 50th, and 75th percentile values; whiskers characterize a range of values up to 1.5 times the IQR; and dots represent outliers beyond this range. IPT, isoniazid preventive therapy; IQR, interquartile range; TB, tuberculosis.
Fig 5
Fig 5. Heatmap of percent decrease in community TB incidence brought about by active diagnosis intervention across ranges of relative TB incidence (prisoner/community) and proportion of population incarcerated.
Assumptions include (A) assortative mixing (3-fold relative rate of contact) for community members and ex-prisoners and (B) proportionate mixing between community members and ex-prisoners. TB, tuberculosis.

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    1. Uplekar M, Weil D, Lonnroth K, Jaramillo E, Lienhardt C, Dias HM, et al. WHO’s new End TB Strategy. Lancet. Elsevier; 2015;385(9979): 1799–1801. 10.1016/S0140-6736(15)60570-0 - DOI - PubMed
    1. Stuckler D, Basu S, McKee M, King L. Mass incarceration can explain population increases in TB and multidrug-resistant TB in European and central Asian countries. Proc Natl Acad Sci. 2008;105(36): 13280–13285. 10.1073/pnas.0801200105 - DOI - PMC - PubMed
    1. Baussano I, Williams BG, Nunn P, Beggiato M, Fedeli U, Scano F. Tuberculosis Incidence in Prisons: A Systematic Review. Menzies D, editor. PLoS Med. 2010;7(12): e1000381 10.1371/journal.pmed.1000381 - DOI - PMC - PubMed
    1. Dara M, Acosta CD, Melchers NVSV, Al-Darraji HAA, Chorgoliani D, Reyes H, et al. Tuberculosis control in prisons: Current situation and research gaps. Int J Infect Dis. 2015;32: 111–117. 10.1016/j.ijid.2014.12.029 - DOI - PubMed
    1. Sacchi FÁVPC, Pra Ç A RM, Tatara MB, Simonsen V, Ferrazoli L, Croda MG, et al. Prisons as reservoir for community transmission of tuberculosis, Brazil. Emerg Infect Dis. 2015;21(3): 452–455. 10.3201/eid2103.140896 - DOI - PMC - PubMed

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